Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer,but we have experienced resistance to the introduction of the FreeHandffrobotic camera holder to augment laparoscopic colorectal surgery.AIM To compare the initial results between conventional and FreeHandffrobot-assisted laparoscopic colectomy in Trinidad and Tobago.METHODS This was a prospective study of outcomes from all laparoscopic colectomies per-formed for colorectal carcinoma from November 29,2021 to May 30,2022.The following data were recorded:Operating time,conversions,estimated blood loss,hospitalization,morbidity,surgical resection margins and number of nodes har-vested.All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.RESULTS There were 23 patients undergoing colectomies for malignant disease:8(35%)FreeHandff-assisted and 15(65%)conventional laparoscopic colectomies.There were no conversions.Operating time was significantly lower in patients under-going robot-assisted laparoscopic colectomy(95.13±9.22 vs 105.67±11.48 min;P=0.045).Otherwise,there was no difference in estimated blood loss,nodal harvest,hospitalization,morbidity or mortality.CONCLUSION The FreeHandffrobot for colectomies is safe,provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center:Value of tailored peri-pancreatectomy protocols

BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.

Liver surface depressions in the presence of diaphragmatic muscular bands on trans-illumination

Traditional descriptions of liver anatomy refer to a smooth,convex surface contacting the diaphragm.Surface depressions are recognized anatomic variants.There are many theories to explain the cause of the depressions.We discuss the theory that these are caused by hypertrophic muscular bands in the diaphragm.

Hepatic grooves:An observational study at laparoscopic surgery

BACKGROUND In traditional descriptions,the upper surface of the liver is smooth and convex,but deep depressions are variants that are present in 5%-40%of patients.We sought to determine the relationship between surface depressions and the diaphragm.AIM To use exploratory laparoscopy to determine the relationship between surface depressions and the diaphragm.METHODS An observational study was performed in all patients undergoing laparoscopic upper gastro-intestinal operations between January 1,2023 and January 20,2024.A thirty-degree laparoscope was used to inspect the liver and diaphragm.When surface depressions were present,we recorded patient demographics,presence of diaphragmatic bands,rib protrusions and/or any other source of compression during inspection.RESULTS Of 394 patients,343 had normal surface anatomy,and 51(12.9%)had prominent surface depressions on the liver.There was no significant relationship between the presence of surface depressions and gender nor the presence of rib projections.However,there was significant association between the presence of surface depressions and diaphragmatic muscular bands(P<0.001).CONCLUSION With these data,the diaphragmatic-band theory has gained increased importance over other theories for surface depressions.Further studies are warranted using cross sectional imaging to confirm relationships with intersectional planes as well as beta-catenin assays in the affected liver parenchyma.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery(MIS)because there are many factors that make laparoscopic pancreas resections difficult.The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries.However,this is not the environment that many surgeons in developing countries work in.These patients often do not have the opportunity to travel to high volume centres for care.Therefore,we sought to review the existing data on MIS for the pancreas and to discuss.In this paper,we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas.The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice.Low pancreatic case volume in the Caribbean,and financial barriers to MIS in general,laparoscopic distal pancreatectomy,enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment.This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Whipple’s pancreaticoduodenectomy at a resource-poor,low-volume center in Trinidad and Tobago

BACKGROUND Many authorities advocate for Whipple’s procedures to be performed in highvolume centers,but many patients in poor developing nations cannot access these centers.We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume,resource-poor setting in the West Indies.AIM To study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1,2013 to June 30,2021.METHODS This was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1,2013 to June 30,2021.RESULTS This center performed an average of 11.25 procedures per annum.There were 72 patients in the final study population at a mean age of 60.2 years,with 52.7%having American Society of Anesthesiologists scores≥III and 54.1%with Eastern Cooperative Oncology Group scores≥2.Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2.Portal vein resection/reconstruction was performed in 19(26.4%)patients.In patients undergoing open procedures there was 367±54.1 min mean operating time,1394±656.8 mL mean blood loss,5.24±7.22 d mean intensive care unit stay and 15.1±9.53 d hospitalization.Six(8.3%)patients experienced minor morbidity,10(14%)major morbidity and there were 4(5.5%)deaths.CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures.Low volume centers in resource poor nations can achieve good short-term outcomes.This is largely due to the process of continuous,adaptive learning by the entire hospital.

Whipple’s operation with a modified centralization concept:A model in low-volume Caribbean centers

Conventional data suggest that complex operations,such as a pancreaticoduodenectomy(PD),should be limited to high volume centers.However,this is not practical in small,resource-poor countries in the Caribbean.In these settings,patients have no option but to have their PDs performed locally at low volumes,occasionally by general surgeons.In this paper,we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations.Specifically,we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating studies published on outcomes after PD in high volume centers.The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept.In the authors’opinions,most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries.In these settings,their only options are to have their operations in the resource-poor,low-volume settings in the Caribbean.However,post-operative outcomes may be improved,despite low-volumes,if a modified centralization concept is encouraged.

Anatomic variations of the intra-hepatic biliary tree in the Caribbean:A systematic review

BACKGROUND In the classic descriptions of the human liver,the common hepatic duct forms at the confluence of left and right hepatic ducts.Many authors have documented variations in the intra-hepatic ductal system,but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.AIM To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography(MRC)in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean.Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.METHODS This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean.We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1,2017 to March 31,2019.Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification.A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant.The variants in our population were compared to the global population.RESULTS There were 152 MRCs evaluated in this study in 86 males and 66 females.There were 109(71.7%)persons with“classic”biliary anatomy(type A1)and variants were present in 43(28.3%)persons.There was no statistical relationship between the presence of anatomic variants and gender or ethnicity.We encountered the following variants:29(19.1%)type A2,7(4.6%)type A3,6(3.95%)type A4,0 type A5 and a single variant(quadrification)that did not fit the classification system.Compared to the global prevalence,our population had a significantly greater occurrence of A1 anatomy(71.7%vs 62.6%;P=0.0227)and A2 trifurcations(19.1%vs 11.5%;P=0.0069),but a significantly lower incidence of A3 variants(4.61%vs 11.5%;P=0.0047).CONCLUSION There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics.Specifically,persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean

BACKGROUND Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease.There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes.These high volume referral centers are usually located in developed countries,but many patients in developing nations are not able to access these centers because of financial limitations,lack of social support and/or travel restrictions.Therefore,local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease.This is the situation in many Caribbean countries.AIM To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean.METHODS We prospectively studied all patients who underwent major liver resections over five years.The following data were extracted:patient demographics,diagnoses,ECOG status,operation performed,post-operative morbidity and mortality.Statistical analyses were performed using SPSS ver 16.0 RESULTSThere were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year.Sixty-nine major hepatic resections were performed for:colorectal liver metastases 40(58%),non-colorectal metastases 9(13%),hepatocellular carcinoma 8(11.6%),ruptured adenomas 4(5.8%),hilar cholangiocarcinomas 4(5.8%),hemangiomata 2(2.9%),trauma 1(1.5%) and hepatoblastoma 1(1.5%).Twenty-one patients had at least one complication,for an overall morbidity rate of 30.4%.There were minor complications in 17(24.6%)patients,major complications in 11(15.9%) patients and 4(5.8%) deaths.CONCLUSION There are unique geographic,political and financial limitations to healthcare delivery in the Caribbean.Nevertheless,clinical outcomes are acceptable in the established,low-volume hepatobiliary centers in the Eastern Caribbean.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections(SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Surgical relevance of anatomic variations of the right hepatic vein

BACKGROUND Variations in the anatomy of hepatic veins are of interest to transplant surgeons,interventional radiologists,and other medical practitioners who treat liver diseases.The drainage patterns of the right hepatic veins(RHVs)are particularly relevant to transplantation services.AIM The aim was to identify variations of the patterns of venous drainage from the right side of the liver.To the best of our knowledge,there have been no reports on RHV variations in in a Caribbean population.METHODS Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center.Venous outflow patterns were observed and RHV variants were described as:(1)Tributaries of the RHV;(2)Variations at the hepatocaval junction(HCJ);and(3)Accessory RHVs.RESULTS A total of 118 scans met the inclusion criteria.Only 39%of the scans found conventional anatomy of the main hepatic veins.Accessory RHVs were present 49.2%and included a well-defined inferior RHV draining segment VI(45%)and a middle RHV(4%).At the HCJ,83 of the 118(70.3%)had a superior RHV that received no tributaries within 1 cm of the junction(Nakamura and Tsuzuki type I).In 35 individuals(29.7%)there was a short superior RHV with at least one variant tributary.According to the Nakamura and Tsuzuki classification,there were 24 type II variants(20.3%),six type III variants(5.1%)and,five type IV variants(4.2%).CONCLUSION There was significant variation in RHV patterns in this population,each with important relevance to liver surgery.Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

Responses to disrupted operative care during the coronavirus pandemic at a Caribbean hospital

The coronavirus pandemic was thrust upon all nations in the year 2020 and required swift public health responses.Resource-poor health care facilities,such as those in the Caribbean,were poorly prepared but had to respond to the threat.In this experience report we examined the response by the surgical specialty to evaluate the lessons learned and to identify positive changes that may continue post-pandemic.

Alternative to mesh repair for ventral hernias: Modified rectus muscle repair

BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections,adhesions,seromas,fistula formation and significant postoperative pain.The modified rectus muscle repair(RMR)is as an option to repair midline ventral hernias without mesh.AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias>5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit.Patients were reviewed in an outpatient clinic at 3,6 and 12 mo and evaluated for hernia recurrence on clinical examination.Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences.All data were examined with SPSS ver 18.0.RESULTS Over the 5-year study period,there were 52 patients treated for ventral hernias at this institution.Four patients were excluded and there were 48 in the final study sample,at a mean age of 56 years(range 28-80).The mean maximal diameter of the hernia defect was 7 cm(range 5-12 cm).There were 5(10.4%)seromas and 1 recurrence(2.1%)at a mean of 36 mo follow-up.CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias.The seroma rate can be further reduced with routine use of drains.The modified RMR also has the benefit of eliminating all mesh-specific complications.

Freehand-robot-assisted laparoscopic colorectal surgery:Initial experience in the Trinidad and Tobago

BACKGROUND Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean,having been first performed in the region in the year 2011.We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.AIM To report our initial experience using the FreeHand®robotic camera holder(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)for laparoscopic colorectal surgery in Trinidad&Tobago.METHODS We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand®(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)robotic camera holder between September 30,2021 and April 30,2022.The following data were recorded:patient demographics,robotic arm setup time,operating time,conversions to open surgery,conversions to a human camera operator,number and duration of intra-operative lens cleaning.At the termination of the operation,before operating notes were completed,the surgeons were administered a questionnaire recording information on ergonomics,user difficulty,requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.RESULTS Nine patients at a mean age of 58.9±7.1 years underwent colorectal operations using the FreeHand robot:Right hemicolectomies(5),left hemicolectomy(1),sigmoid colectomies(2)and anterior resection(1).The mean robot docking time was 6.33 minutes(Median 6;Range 4-10;SD±1.8).The mean duration of operation was 122.33±78.5 min and estimated blood loss was 113.33±151.08 mL.There were no conversions to a human camera holder.The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6±0.88 times per case,with cumulative mean interruption time of 4.2±2.15 minutes per case.The mean duration of hospitalization was 3.2±1.30 days and there were no complications recorded.When the surgeons were interviewed after operation,the surgeons reported that there were good ergonomics(100%),with no limitation on instrument movement(100%),stable image(100%)and better control of surgical field(100%).CONCLUSION Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting,once there is appropriate training.